An example of a Chinese urban medical insurance policy, what is the medical insurance policy

1. The highest reimbursement ratio for outpatient reporting in 2018 has been increased to 55%. Among them, the outpatient threshold of hospitals at and below the level of urban residents has been reduced to 100 yuan, and the annual cap of outpatient services has been unified to 3,000 yuan.

2. The highest reimbursement ratio of Xiangran's hospitalization has reached 80%, and the annual ceiling line of hospitalization has been increased to 200,000 yuan.

3. From January 1, 2018, the reimbursement ratio for serious illness has been increased from 16,500 yuan in 2017 to 19,000 yuan. Among them: less than 50,000 yuan, 50% of which is borne by individuals; 5-100,000 yuan, 45% of personal responsibility; 10-150,000 yuan, 40% for individuals; 15-200,000, 35% per person; For more than 200,000 yuan, 30% shall be borne by the individual.

In addition, Class C drugs, imported drugs, and self-financed drugs are not included in the scope of reimbursement.

Legal basis: Regulations of the People's Republic of China on Basic Medical Insurance for Urban Employees

Article 4 The basic medical insurance premiums shall be borne jointly by the employer and the employee.

Fifth basic medical insurance in principle to the city, county, autonomous county as the overall unit, the implementation of localized management.

Sixth basic medical insurance premiums by the provincial local taxation authorities (hereinafter referred to as the collection authorities) levy.

1. Who is covered by the medical insurance system for urban and rural residents?

The coverage of the medical insurance system for urban and rural residents includes all the insured persons of the existing urban residents' medical insurance and the New Rural Cooperative Medical System, that is, all urban and rural residents except for the persons who should be insured by the basic medical insurance for employees. Migrant workers and flexibly employed persons participate in the basic medical insurance for employees in accordance with the law, and those who have difficulties can participate in the medical insurance for urban and rural residents in accordance with local regulations.

2. How to increase the proportion of individual contributions?

In areas where there is a large gap between the existing urban residents' medical insurance and the NCMS individual payment standards, the method of differential payment can be adopted, and the transition can be made in 2-3 years. After consolidation, the actual per capita financing and individual contributions shall not be lower than the current level.

Gradually establish a mechanism for linking individual payment standards with the per capita disposable income of urban and rural residents. Reasonably divide the financing responsibilities of individuals and individuals, and appropriately increase the proportion of individual contributions while increasing the subsidy standards.

III. How are the funding criteria determined?

All localities should take into account the needs of urban and rural residents for medical insurance and serious illness insurance, and reasonably determine the unified financing standards for urban and rural areas in accordance with the principle of balancing revenue and expenditure. In areas where there is a large gap between the existing urban residents' medical insurance and the new rural acacia for individual payment standards, the method of differential payment can be adopted, and the transition can be gradually made in 2-3 years. After consolidation, the actual per capita financing and individual contributions shall not be lower than the current level.

Fourth, how to balance the protection treatment?

In accordance with the principle of appropriate security and balance between revenue and expenditure, we should balance the treatment of urban and rural security, and gradually unify the scope of security and payment standards. Medical insurance for urban and rural residents** is mainly used to pay for the hospitalization and outpatient medical expenses incurred by the insured. Stabilize the level of hospitalization protection, and maintain the proportion of hospitalization expenses within the policy at about 75.

Further improve the overall planning of outpatient services, and gradually increase the level of outpatient protection. Gradually narrow the gap between the proportion of payment within the scope of the policy and the actual proportion of payment.

5. How much can medical insurance pay after hospitalization?

Medical insurance for urban and rural residents** is mainly used to pay for inpatient and outpatient medical expenses incurred by insured persons. Stabilize the level of hospitalization protection, and maintain the proportion of hospitalization expenses within the policy at about 75. Further improve the overall planning of outpatient services, and gradually increase the level of outpatient protection.

Gradually narrow the gap between the proportion of payment within the scope of the policy and the actual proportion of payment.

1. Insured objects: urban and rural residents who do not have any medical insurance and school students in the city, non-school residents under the age of 18, and those who participate in the child co-ordination of the original government agencies and institutions. (Except for those who participate in employee medical insurance) Second, the individual payment standard:

80 yuan per person per year for students and 150 yuan per year for other residents. 3. Agreed procedures and treatment methods of designated medical institutions: sign a service agreement with the community health service center agreed upon by yourself with the insurance registration form and medical records.

If it needs to be changed in the next year, it should be taken from October 1 to December 20 of the current year to go through the relevant procedures at the community hospital where the "citizen card" and the "medical record card" need to be re-agreed. Insured residents should first go to the agreed community hospital for medical treatment, and if the community hospital cannot treat the disease, the community hospital will go through the referral procedures (valid for three days), and then go to the designated hospital in the city and outside the city for treatment. 4. Medical treatment:

1. Outpatient expenses: 600 yuan per year. 50% of visits to community hospitals were reported; 40% of the visits to hospitals in the city and outside the city were settled, and the reimbursement rate of those who did not make referrals was halved.

2. Hospitalization: There is no minimum payment in community hospitals; Hospitals in and out of the city pay 300 yuan for students and 600 yuan for residents, and the minimum fee for those who have not been referred is doubled. Hospitalization reimbursement rate above the threshold standard:

80% of community hospitals settled; The settlement and reimbursement rate of hospitals in the city and outside the city were respectively, and the settlement and reimbursement rate of those who did not handle referrals was halved, and the maximum annual medical expenses were 170,000 yuan. 3. Medical expenses for childbirth: the maximum amount of each fee shall not exceed 3,000 yuan.

Social Insurance Law of the People's Republic of China

Article 4 Employers and individuals within the territory of the People's Republic of China who pay social insurance premiums in accordance with law have the right to inquire about payment records and records of individual rights and interests, and to request social insurance agencies to provide social insurance consultation and other related services. Individuals enjoy social insurance benefits in accordance with the law, and have the right to supervise their own units' contributions for them.

Article 5: The people at or above the county level shall include social insurance undertakings in their national economic and social development plans. The state raises social insurance funds through multiple channels. The people at or above the county level shall give necessary financial support to the social insurance undertakings.

The state supports social insurance through preferential tax policies.

Legal analysis: The social medical insurance card, referred to as the medical insurance card or medical insurance card, is a special card for medical insurance personal accounts, with personal ID card as the identification code, storing and recording personal ID number, name, gender, account allocation, consumption and other detailed information. The balance of the medical insurance card cannot be cashed out, and it is illegal to cash out the balance of the medical insurance card in various names.

Legal basis: "Social Insurance Law of the People's Republic of China" Article 27 Individuals who participate in the basic medical insurance for employees who have reached the retirement age of the State shall not pay the basic medical insurance premiums after retirement and enjoy the basic medical insurance benefits in accordance with the provisions of the State; If the number of years prescribed by the state has not been reached, the fee can be paid until the number of years prescribed by the state.

Legal analysis: employees shall participate in the basic medical insurance for employees, and the employer and the employee shall jointly pay the basic medical insurance premiums in accordance with the national regulations, and if the cumulative payment reaches the statutory retirement age for the number of years specified by the state, the basic medical insurance premiums shall not be paid after retirement, and the basic medical insurance benefits shall be enjoyed in accordance with the provisions of the state; If the number of years prescribed by the state has not been reached, the fee can be paid until the number of years prescribed by the state.

Legal basis: Social Insurance Law of the People's Republic of China

Article 23 Employees shall participate in the basic medical insurance for employees, and the employer and the employees shall jointly pay the basic medical insurance premiums in accordance with the provisions of the State.

Individually-owned businesses without employees, part-time employees who have not participated in the basic medical insurance for employees in the employer, and other flexibly employed persons may participate in the basic medical insurance for employees, and the individual shall pay the basic medical insurance premiums in accordance with the provisions of the state.

Article 27 Individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, the cumulative contributions reach the number of years prescribed by the State, and the basic medical insurance premiums shall not be paid after retirement, and they shall enjoy the treatment of basic medical insurance in accordance with the provisions of the National Cruise Tour; If the number of years prescribed by the state has not been reached, the fee can be paid until the number of years prescribed by the state.